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Ci <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord m -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. �, m <br /> l-Orroear, T41e <br /> n f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> a(91010 Logan Lane <br /> Address Ury GOl Address <br /> SR2oner LcJI J o <br /> City, State, Zip Code City, State, Zip Code <br /> 715-- 1635 - 736 3 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name Q6600 Lor1 Lon C <br /> Legal Description (as indicated on tax statement)S'' NE -4 �lv y .NW y 5eC 11/39 /Z/ m <br /> n 0 <br /> Permit(s) Applied for: 0 �. <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> z o <br /> Accessory Building X Sanitary Privy Subdivision ° $ <br /> Garage <br /> Structure Use: _ P <br /> ri (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). M 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 0 3 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream-if within u c <br /> 300 ft. 40 o n <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building m H <br /> to lake, river or stream, if applicable. r <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. ♦A <br /> m <br /> PLOT PLAN ` <br /> N <br /> 00C <br /> NDm <br /> o <br /> c N tYr ' ' <br /> 4X3a <br /> � Z <br /> '907 ,01 <br /> �a ,va w <br /> ay jMX3'A 403 ` f <br /> goo m O c J. 0 o a * m <br /> D Z .m . 1 <br /> P .0i a <br /> —n m <br /> c <br /> 8 : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- a <br /> o m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit.'I, <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have u <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m m A n <br /> SIGN HERE —� a <br /> (signature of owner or building contractor) (date) o s <br /> ZONING ADMINISTRATOR "'m �'�J1 X11 V [ 8 . <br /> a <br /> TOWNSHIP PERMITS MAY BE REQUIRED " M " 000o <br />